UNIVERSITY OF MAKATI

College of Allied Health Studies

J.P. Rizal Extension, West Rembo, Makati City

A Case Presentation
On

Spontaneous Pneumothorax
In Partial Fulfillment of the Requirements in Medical and Surgical Nursing I

Submitted By: Aloba, Kenosis P. De Asis, Kenneth Generao, Ginalyn Lupango, Jessa Olino, Caren Rustia Oliveros, Juan Miguel Orillaneda, Jean Pasco, John Carlo Sale, Rhechell C. Sulangi, Angela

MS1 Group 2 May 26, 2012

TABLE OF CONTENTS

CHAPTER 1:

INTRODUCTION Objectives HEALTH HISTORY I. Patients Profile II. Chief Complaint III. History of Present Illness IV. Past medical History V. Family Medical History VI. Personal and Social History PHYSICAL ASSESSMENT REVIEW OF SYSTEMS GORDONS FUNCTIONAL HEALTH PATTERN MEDICAL AND NURSING DIAGNOSIS LABORATORY EXAMS COURSE IN THE WARD ANATOMY AND PHYSIOLOGY

3 5

CHAPTER 2:

6 7 7 8 9 9 10 13 15 16 17 24 31 34 35 37 50 61 63
2

CHAPTER 3: CHAPTER 4: CHAPTER 5: CHAPTER 6: CHAPTER 7: CHAPTER 8: CHAPTER 9:

CHAPTER 10: DIFFERENTIAL DIAGNOSIS CHAPTER 11: PATHOPHYSIOLOGY CHAPTER 12: NURSING CARE PLAN CHAPTER 13: DRUG STUDY CHAPTER 14: DISCHARGE PLANNING CHAPTER 15: REFERENCES

CHAPTER 1:

INTRODUCTION

Six members of the group have handled the case, Spontaneous Pneumothorax during their duty at the General Ward of Ospital ng Makati last May 7 to May 8, 2012. The group has noticed Mr. E. T. L. among other patients because they believe that a lot of people are still unaware about the condition, how it occurs and how it is managed. Only few studies were made about spontaneous pneumothorax. Little information was also provided even on books and on the internet. Our group wanted to expand and share what we have learned about this study. For us to come up with a better study, our group has interviewed several health care providers such as a doctor, a nurse, and a respiratory therapist. Mr. E. T. L. was conscious and coherent throughout the interview and assessment, so he was able to express all of his concerns. This study mainly focuses on the proper assessment, diagnosis, plan of care, and intervention for spontaneous pneumothorax. It also gives on the understanding of the disease process in relation to the patients medical history. Pneumothorax (pl. pneumothoraces) is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall, and that may interfere with normal breathing. It occurs when the parietal or visceral pleura are breached and the pleural space is exposed to positive atmospheric pressure. Normally, the pressure in the pleural space is negative. This negative pressure is required to maintain lung inflation. When either of them is breached, air enters the pleural space and the lung or a portion of it collapses. The types of pneumothorax include simple, traumatic, and tension pneumothorax. A simple, or spontaneous, pneumothorax may occur in an apparently healthy person in the absence of trauma due to rupture of an air-filled bleb, or blister, on the surface of the lung, allowing air from the airways to enter the pleural cavity. The spontaneous pneumothorax is either a primary or a secondary pneumothorax. Primary Spontaneous Pneumothorax is the air in the pleural space without preceding trauma and without underlying clinical or radiologic evidence of lung disease. Secondary Spontaneous Pneumothorax occurs in patients with underlying pulmonary structural pathology. Air can enter the pleural space via distended, damaged, or compromised alveoli. It may present with more serious clinical symptoms and sequel due to comorbidity. Pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, asthma, and infections of the lungs. A Traumatic Pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. It may result from a blunt trauma (e.g. rib fractures), penetrating chest or abdominal trauma (e.g. stab wounds or gunshot wounds), or diaphragmatic tears Open Pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Such injuries are called sucking chest wounds due to the rush of air producing a sucking sound. Not only does the lung collapse, but the structures of the mediastinum (heart and great vessels) also shift 3

toward the uninjured side with each inspiration and in the opposite direction with expiration. This is called the mediastinal flutter or swing. A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall. Relief of tension pneumothorax is considered an emergency measure. The risk factors that a person is more likely to develop pneumothorax include: sex (occurs more in males than females, 4:1 ratio), age (20-40 yrs), tall and thin body built, history of smoking, change in atmospheric pressure, previous history of pneumothorax, family history, underlying chronic lung disease (e.g. emphysema, asthma, tuberculosis, pneumonia, cystic fibrosis and lung cancer), medical procedures (e.g. Thoracentesis), and mechanical ventilation. Symptoms of a pneumothorax include chest pain that usually has a sudden onset. The pain is sharp and may lead to feelings of tightness in the chest. Shortness of breath, rapid heart rate, rapid breathing, cough, and fatigue are other symptoms of pneumothorax. The skin may develop a bluish color due to decreases in blood oxygen levels. Rapid, shallow and asymmetric respirations may be observed. Hyperresonance upon chest percussion and diminished or absent breath sounds, and decreased tactile fremitus on the affected lung field are evident.

Number of incidences: According to the Stockholm study of worldwide frequency of pneumothorax 2011, one of the largest epidemiologic studies performed, pneumothorax occurs in 18 per 100,000 men and 6 per 100,000 women per year. The study also showed that COPD was the primary cause of pneumothorax development. About 22 of 45 patients with COPD develop pneumothorax. Recurrence will occur in about 30% of primary and 45% of secondary pneumothorax. It often occurs within 6 months, and usually within 3 years.

OBJECTIVES

A. General objective:

The study conducted by our group aims to acquire sufficient knowledge of the disease process, how it develops and its management. Another objective is to gain full awareness of the medical procedures done during hospitalization. The study also serves to aid us in formulating possible Nursing Care Plans for patients with Pneumothorax. It will help us apply the knowledge and skills gathered from this case to other cases that will be encountered in the future.

B. Specific objective: Student-centered: To conduct a research regarding the patients condition. To discuss the underlying problem of our chosen case and give a clear view of it. To be able to provide a comprehensive nursing history to identify the cause of Spontaneous Pneumothorax To enhance our nursing skills in identifying and classifying signs and symptoms of the patient with Spontaneous Pneumothorax. To hone us to become competitive nurses in the future. To be able to execute the effective nursing interventions that may help promote the well being of the patient and decrease risk for further complications. To assess the patients response to the treatment and evaluate the effectiveness of the nursing care given. To review the Anatomy and Physiology of the system related to the disease. To be aware of the pathophysiology of the disease.

Client-centered: The patient will become aware of his existing condition and the different treatment modalities that are available to him. For the client to realize factors that contributes to his disease and how he can modify these factors. For the client to assist himself during discharge by health teaching contributed by the nurse. For the client to turn towards the preventive behavior to avoid recurrence of the present condition in the future.

CHAPTER 2:

HEALTH HISTORY

I.

PATIENTS PROFILE: Mr. E. T. L. Male 36 years old. Married Filipino August 26, 1975 Valenzuela City Guadalupe, Makati Roman Catholic High School Graduate Bag seller at the Guadalupe market May 6, 2012 8:15 AM Ambulatory 6

Name: Sex: Age: Civil Status: Nationality: Birth date: Birth Place: Address: Religion: Educational Attainment: Occupation: Date and time of admission: Mode of admission:

Admitting Diagnosis: Preoperative Diagnosis: Operation Performed: Postoperative Diagnosis: Informant: Percentage Reliability:

Spontaneous Pneumothorax Massive Pneumothorax Left Secondary to Ruptured Bleb vs Idiopathic Emergency Chest Tube Thoracostomy, Left Status post The patient himself 90%

II.

CHIEF COMPLAINT: Difficulty of breathing for two weeks.

III.

HISTORY OF PRESENT ILLNESS:

2 weeks Prior to Admission, the client experienced difficulty of breathing and had a fever of 38.1C. He was then rendered a tepid sponge bath by his wife and took a tablet of Paracetamol 500mg for his fever. After 1hour, his temperature went down from 38.1C to 37.7C, but his fever persisted for 2 days. He also took Salbutamol 4mg for his difficulty of breathing during the night and was able to fall asleep. 1 week and 4 days prior to Admission, the difficulty of breathing still persisted. Because of that, the client used water steam inhalation and his wife did back clapping. He took again Salbutamol 4mg, but only once per day. The symptoms were relieved only for a short time. There was persistence of symptoms. No improvement or progression was stated. 2 days Prior to Admission, the client went to an OPD at Polymedic Clinic for consult and was advised for admission. However, the client decided to stay at home against medical advice. 1 day Prior to Admission 8Pm, the client was sent to the emergency room at OSMAK with difficulty of breathing and was subsequently diagnosed of impending thyroid storm. Oxygen was then administered at 4L/M via nasal cannula. Intravenous Fluid of D5LR was also administered to the patient. After that, he was then sent home.
7

At home, the client experienced chest pain, palpitations and shortness of breath. Hence, he went back to the emergency room at 1:27am, the next day, and was scheduled for an Emergency Chest Tube Thoracostomy on the left lung.

IV. PAST MEDICAL HISTORY:

The client received complete immunization during childhood. He was also never admitted to any hospitals in the past. He has no known allergies. The client also has no history of injuries or falls. He has no history of any type of pneumothorax. He goes to clinics for a check-up whenever he is feeling unwell. No recent travel was also made. DATE 5 yrs old DIAGNOSIS Bronchial Asthma HOSPITAL None INTERVENTION Prescribed MEDICATIONS Salbutamol Poor compliance Was only compliant with medications from yr 20052008. Unrecalled

2005

Hyperthyroidism

Manila Doctors Hospital

Unmanaged

V.

FAMILY MEDICAL HISTORY:

Interpretation: The father and grandfather of Mr. E. T. L. died of emphysema. That means that he is at risk of developing emphysema as well. His family also had a history of smoking. His uncle on the father side and younger sister are asthmatic. On the mother side, his mother and aunt are hypertensive and diabetic. His uncle is also known to be a diabetic. His eldest sister was also diagnosed with hyperthyroidism.

VI. PERSONAL AND SOCIAL HISTORY:

The client and his wife are bag sellers for 3 years with their own stall at the Guadalupe Market. Their gross income is 20,000/month. He is a high school graduate at Bangkal High School in Makati City. The client lives in his own house, together with his wife and mother. His house is a bungalow style with two bedrooms. He stated that their environment is clean and has enough space for all of them. They didnt have any children. The client started smoking at 15 years old and smokes at least half a pack of cigarettes per day and also drinks alcohol occasionally.

CHAPTER 3:
DATE AND TIME: May 7, 2012 General appearance:

PHYSICAL ASSESSMENT
9:00am 11:00am

(+) facial grimace Conscious and coherent Thin body figure Cooperative and responds appropriately to every question asked at moderate pace and as long as he can tolerate.

Anthropometric measures:

Height: 172.72 cm Weight: 54.4kg BMI *18.2 (Normal values are 18.5-25)

Vital signs:

Temperature: Respiratory rate: Pulse rate: Blood pressure:

37.3 C 27 cpm 105 bpm 130/80 mmHg

ORGAN/BODY PARTS Skin

METHODS USED Inspection

FINDINGS *Hematomas on antecubital and radial surface on both arms (-) cyanosis Dark complexion Intact skin Good skin turgor Normocephalic (-) Head injury (-) Tenderness (-) Lesions (-) hair parasites (-) dandruffs Hair is evenly distributed Normal facial movements

SIGNIFICANCE *Hematomas are due to blood samples taken

Head

Palpation Inspection

Normal

Hair

Inspection

Normal

Face

Inspection

Normal

10

Eyes

Inspection

PERRLA: Pupils are equal and round, left eye 3 mm reactive to light and right eye 3 mm reactive to light, good accommodation noted. *slightly protruding eyes *Dark circles around the eyes Bilaterally equal in size (-) lesions (-) discharge (-) redness (-) bleeding Able to hear sounds on both ears and distance Pinna is firm, non tender and no pain Symmetric and straight (-) discharges (-) nasal flaring With O2 administered at 4L/min via nasal cannula

Ears

Inspection

* Eye protrusion is one of the signs of hyperthyroidism *Possible sleep deprivation Normal

Watch tick test Palpation Nose: Inspection

Normal

O2 Therapy is used to benefit patient by increasing the supply of O2 to the lungs and thereby increasing the availability of O2 to the body tissues There could be difficulty in mastication.

Mouth:

Inspection

Neck:

Inspection

*(+) dental carries *Absence of teeth on upper mandible Uniform and pinkish tongue with no lesion, Moist pink buccal mucosa Symmetric and head centered (+) swollen lymph nodes (+) Lump on the center of the neck Size and location and movability and

Palpation

There could be presence of infection There is thyroid enlargement

11

tenderness Upper Extremities Inspection With IV contraption on R metacarpal infusing PNSS 1L x 40cc/min *20.5cm mid-upper arm circumference Equal pulses

Palpation

*Normal value of MIUC in adult males is 23cm. This shows decreased amounts of fat and muscle mass in the arms

Nails:

Inspection Palpation

Thorax and lungs:

Inspection

(-)Pallor (-) Indentations Capillary refill less than 3 seconds With CTT one-way drainage system inserted on the 5th ICS, LMA line (+)chest wall retraction (+) use of accessory muscles (+) shallow breathing Diminished breath sounds and pleural rub on left lung Hyper resonance on left lung Tactile fremitus decreased on left lung (-) visible pulsation No heart murmurs auscultated over aortic, pulmonic, tricuspid and mitral area. Normal heart rate and regular rhythm HR = 105bpm (+)Tachycardia (-)swelling (+) bowel sounds on four quadrants (-) palpable masses and no tenderness. No swelling, no lesions

Normal *To remove air in the pleural space

*Patient is having problems with oxygenation

Auscultation

Percussion Palpation Heart Inspection Auscultation

*Air in the pleural space dampens the transmission of sounds and vibration.

Abdomen

Inspection Auscultation Palpation

Heart compensates to increase oxygenation Normal

Genito-urinary

Inspection

Normal 12

Lower Extremities

Inspection

noted Legs symmetric, no ulcerations noted. *(+) limited ROM *(+) body malaise Equal pulses (-) Pail (-) Indentations Capillary refill less than 3 seconds

*Due to weakness

Nails:

Inspection Palpation

Normal

CHAPTER 4:

REVIEW OF SYSTEMS

SYSTEM General

CUES Medyo nanghihina pa ako. May konting sakit sa mga parte na pinagkuhaan ng dugo Pantay ang pandinig ko. Parehas malinaw ang paningin ko. Nahihirapan akong lumunok, Hirap akong huminga. Masakit yung sa gilid ng dibdib ko, parang tinutusok tusok.

INTERPRETATION (+) body malaise

SIGNIFICANCE Body weakness is attributed to the present condition Tenderness is due to puncture of skin from obtaining blood specimen.

Skin/Integumentary System EENT Ears Eyes Throat Respiratory System

(+) Tenderness

Is able to hear on both ears Is able to see on both eyes Difficulty in swallowing DOB Pain on the Left lateral chest P Exacerbates when coughing and moving. Q- Stabbing pain S- 6/10

Normal Normal Brought about by thyroid enlargement Due to escape of oxygen into the pleural space.

13

R Radiates to the left shoulder T 5-10 sec Cardiovascular System May oras na mataas ang bp ko. BP BP is due to increased force of cardiac contractility and the bodys attempt to increase tissue perfusion and oxygenation

Gastrointestinal System

Genitourinary System

Musculoskeletal System Neurologic

Hindi naman ako nagtatae Nagsuka ako kanina dahil sa sama ng pakiramdam ko. Regular ang ihi ko, normal ang color at hindi rin masakit umihi. Wala akong mga almoranas Madali akong mapagod.

(-) Diarrhea Vomiting Attributed to present condition

Normal

Di naman ako ulyanin.

(+) muscle weakness Limited ROM Is able to communicate

Weakness is attributed to present condition and limited ROM Normal

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CHAPTER 5:

GORDONS FUNCTIONAL HEALTH PATTERN

Before hospitalization Health perception and Health Management pattern Client seeks medical consultation every time he feels that there is something abnormal with his health. He takes over the counter drugs when he experiences a cough or cold. He is fond of eating salty and fatty foods. *analysis and interpretation Elimination pattern He defecates at least 2 times a day and urinates at least 6 times a day. He plays badminton every day. Has lack of sleep. The client can hear clearly. Cognitive and alert..Client plays crossword puzzles.

During hospitalization Client is adherent to the treatment regimen

Nutritional and metabolic pattern

He eats what the dietary department serves. On low salt and low fat diet.

Client uses a urinal to urinate. He has not made any bowel movement since hospitalization. Is unable to ambulate due to presence of CTT. Has more difficulty of sleeping. The client can hear clearly. PERRLA.

Activity-exercise pattern Sleep-rest pattern Cognitive perceptual pattern

Self-perception and self Confident and he has a concept pattern good outlook on the way things are happening. Role relationship Is satisfied with family, work, and

The client still has a positive outlook.

He cannot perform his roles as of the moment.

15

social relationships Sexual pattern Is satisfied with sexual relationship. Sex with other women. Client manages stress listening to music. Client prays often for good health. He has no sexual activity.

Coping/ Stress Tolerance Value Belief

Client handles stress of condition by practicing a regular breathing pattern. Client often reads the bible.

CHAPTER 6:

MEDICAL AND NURSING DIAGNOSIS

Medical diagnosis: Spontaneous Pneumothorax

Nursing diagnosis: 1. Ineffective breathing pattern related to decreased lung expansion. 2. Impaired gas exchange related to decreased lung expansion secondary to air accumulation in the pleural space. 3. Acute Pain related to impaired pleural integrity 4. Disturbed sleep pattern related to interruptions from therapeutic regimen, monitoring and other generated awakening and excessive stimulation. 5. Activity intolerance r/t muscle weakness and fatigue 6. Risk for injury related to dependence on chest tube drainage system. 7. Risk for falls related to generalized weakness. 8. Risk for deficient fluid volume related to treatment regimen. 9. Risk for constipation related to changes in level of activity. 10. Risk for prone behavior related to lack of knowledge about the disease.

16

CHAPTER 7:

LABORATORY EXAMS

Hematology Component Result Normal Value Interpretation

05-06-12 Analysis

Hemoglobin

16.8

14-18 g/L

Normal

Hematocrit

0.52

0.40-0.54

Normal Insight: Usually, elevated WBC is an indicator of infection. But in some cases with inflammation or trauma such as spontaneous pneumothorax, it may also lead to increase WBC even without infection.

WBC count

15.9

4-11 x10 g/L

Increased

RBC count

5.8

5.0-6.4

Normal

Differential count: Low eosinophil level is usually not a cause for concern and is actually quite common. Neutrophil is bodys primary defense against bacterial infection and physiologic stress. neutrophils may indicate presence of infection 17

Eosinophils Neutrophils Segments

0.01

0.02-0.04

Decreased

0.71

0.50-0.70

Increased

Lymphocytes

0.16

0.20-0.40

Decreased

Monocytes

0.4

0.02-0.05

Increased

Low lymphocyte counts may occur in normal individuals. . A low value doesnt necessarily mean a decrease in protection against viruses.

Platelet count PT

202 16.3 secs

150-450 x10 g/L 10.4-14.05

Normal Slow

The prothrombin time can be prolonged as a result of deficiencies in vitamin K, warfarin therapy, malabsorption In addition, poor factor VII synthesis (due to liver disease) or increased consumption (in disseminated intravascular coagulation) may prolong the PT. In chronic liver disorders, an increasing INR indicates progression to liver failure. The INR does not increase in mild hepatocellular dysfunction and is often normal in cirrhosis. Probable coagulation factor deficiency (e.g. hemophilia).

% activity INR

57.0% 1.52

73-127% 0.88-1.21

Decreased Increased

Activated PTT

48.0 secs

30.4-41.2

Slow

Nursing implications: Assess for fatigue, dietary deficiencies and V/S. Assess fluid balance and respiratory status.

18

Clinical chemistry 05-07-12 2:50PM

Component Sodium Result 134 mmol/L Normal Value 135 148 mmol/L Interpretation Decreased Analysis contributory factor to lethargy and muscle weakness

Potassium

4.3 mmol/L

3.5 4.5 mmol/L

Normal

Chloride

97 mmol/L

98 107 mmol/L

Decreased

Due to potassium deficiency

Calcium, Ionized

1.08 mmol/L

1.12-1.32 mmol/L

Decreased

Calcium, Total

1.88 mmol/L

2.15-2.55 mmol/L

Decreased

Magnesium

0.63 mmol/L

0.66-0.99 mmol/L

Decreased

Reason of prolonged QT interval in the ECG and PT Tends to cause low serum calcium concentration

Phosphorus

1.68 mmol/L

0.81-1.58 mmol/L

Increased

Clinical chemistry
Component Result Normal Value Interpretation

05-07-12 7:14AM
Analysis

Glucose (fasting)

6.84 mmol/L

4.1 - 5.5 mmol/L

Increased

May predispose the client to DM

Cholesterol

2.73 mmol/L

0.0 5.2 mmol/L

Normal

Triglycerides

0.83 mmol/L

0.0 2.3 mmol/L

Normal May predispose the client to development of CAD

HDL -cholesterol

0.51 mmol/L

0.9 1.45 mmol/L

Decreased

LDL cholesterol

1.66 mmol/L

0.0 2.59 mmol/L

Normal

19

Blood chemistry
Component Result Normal Value Interpretation

05-07-12
Analysis

Blood Urea Nitrogen

3.9 mmol/L

2.1-7.1 mmol/

Normal

BUN is affected by hydration, hepatic metabolism of protein and reduced GFR BUN indicates kidney damage, GFR

Serum creatinine

60 mmol/L

45-104 mmol/L

Normal

serum Crea indicates nephron damage, GFR

Nursing implications: Assess kidney function and check Input and Output. * Mr. E. T. L. as indicated in his blood chemistry is having a normal renal function.

STOOL EXAM Macroscopic Examination: Color: Consistency: Gross Evidence of: >WBC >RBC Remarks:

05-06-12

Light Brown Soft

0-3/HPF 0-2/HPF No intestinal Parasites seen

20

URINALYSIS
Component MACROSCOPIC EXAM: Color Transparency Dark Yellow Slightly Hazy Result

05-06-12
Interpretation

Dehydration is the most common condition that can produce yellow urine. Normal urine is transparent. Normal turbid urine includes precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria.

Sugar Protein pH S.G. MICROSCOPIC EXAM: WBC RBC Epithelial Cells Crystals Bacteria

N (-) +2 6.0 1.025

Equivalent to 100mg/dl. >2+ in concentrated or dilute urine indicates significant proteinuria Normal pH Normal S.G.

0-2/ HPF 1-3/ HPF FEW Amorphous Urates / Phosphates: Occasional FEW

Normal Normal Renal epithelial cells normally appear in the urine in small numbers. Normal Normal

CHEST X-RAY
TYPE: In-patient Examination: Remarks: Department of Medicine General Ward Chest -Follow up chest x-ray after a few hours shows complete reexpansion of the left lung with no evidence of pneumothorax -Left sided CTT seen in place.

05-06-12

21

Electrocardiogram Test (ECG)

ABNORMAL FINDINGS Poor R progression ST-T abnormality (Ant, Lat) Negative T (Inf) Right axis deviation

MAY 6, 2012
INTERPRETATION Increase the magnitude of the voltage in the leads from V1 to V4 Ventricular conduction abnormalities and rhythms originating in the ventricles. Represents ventricular repolarization rhythms originating in the ventricles. congenital heart condition wherein the electrical conduction of the heart is greater than +105 degrees. Between +90 degrees and +180 degrees the condition may be termed Indeterminate Deviation or more often Extreme Right Axis Deviation. factor for sudden cardiac death, Since medications can promote or exacerbate the condition, detection of QT interval prolongation is important for clinical decision support. intraventricular conduction abnormalities secondary to myocardial degeneration. cardiac arrhythmia or irregular heart beat. The ventricles contract irregularly, leading to a rapid and irregular heartbeat.

QT prolongation

Clockwise rotation Atrial Fibrillation

Noise or baseline drift is present ( V1, V6)

Nursing Implications: Explain the purpose of the test and explain that there will be no pain from the test. Explain the procedure of the test. The test may be performed when the patient is fully awake, drowsy, undergoing stimuli, asleep, during sleep deprivation, under sedation, or other situations. Prepare the patient: Restrict only sedatives and/or stimulants such as caffeine, alcohol, etc. prior to the test. Patient Teaching: Be sure to include family in the teaching process. The machine may look frightening to the patient. Reassure the patient that he will not get a shock from the machine, especially if this is the first time this patient will have this test. Patients have other misconceptions and fears about the test. Report to the physician if the patient is taking any medications. Some drugs (legal or otherwise) may affect the results of the test. Report if the patient is unusually anxious or upset before the test. The patient will be carefully observed during the test. Ask the patient to relax and lay still during the test. Usually, normal activity may resume after the test. 22

LIVER ENZYMES
Component S.I. Result Normal Value Interpretation

05-07-12 11:06 PM

AST (SGOT)

41u/L

15-37 u/L

Increased

ALT (SGPT)

37u/L

30-65 u/L

Normal

AST is normally found in red blood cells, liver, heart muscle tissue, pancreas, and kidneys. AST may involve prolonged intake of several medication, alcoholism, or due to hyperthyroidism

Arterial Blood Gas

Component Result Normal Value

05-08-12 3:40PM
Interpretation

PH : pCO2: pO2 HCO3: B.E Sat O2 Total CO2:

7.455 30.2 mm/Hg 97.5 mm/Hg 22.9 mmol/L 1.9 mmol/L

7.350-7.450 35.00-45.00 80.00-100.00 22 26 mEq/L +3 to -3 mEq/L 95-100 23-30mmol/L

Normal Decreased Normal Normal Normal Normal Decreased

97.8 % 21.7 mmol/L

23

CHAPTER 8:

COURSE IN THE WARD

May 07, 2012 6am-2pm shift Time 6:00 am

Data -received pt. in high fowlers position, conscious and coherent - with O2 support via nasal cannula at 4LPM - With IV contraption on R metacarpal infusing PNSS 1L x 40cc/min -with CTT to thoraco bottle on L lower lateral chest wall at 300 water peak level. Initial H2O in CTT: 200

Action -maintain pt. in high fowlers position.

Response

-maintain o2 support via nasal cannula at 4lpm -monitored IV rate

-monitored placement and patency of CTT

6:30 am

Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako. >Dark circles around the eyes > Weakness and restlessness. >Naps whenever possible >Yawning

>Assessed sleep pattern disturbances associated with the environment. >Observed and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest. >Did as much care as possible without waking up the client and do as much care as possible while the client is still 24

7:00 am

awake. >Explained necessity of disturbances for monitoring Vital Signs and care when hospitalized. -v/s taken and recorded

-Temp : 36.8c RR: 27 cpm PR: 105 bpm BP: 130/80 mmHg

-chest tube tubings, dressing and patency was checked

-chest tube are patent, tubings are hang in straight line from mattress to the drainage bottle

-medication given: methimazole 20mg 1tab PO after breakfast 7:14am -clinical chemistry done -chest tube tubings, dressing and patency was checked -Chest tube is patent, tubings are hanged in a straight line from mattress to the drainage bottle

7: 30am

Nahihirapan akong huminga Parang hinihingal ako. RR 27cpm

>Auscultated breath sounds >evaluated respiratory function. >Maintained the 25

>(+) facial grimace >(+) difficulty of breathing >(+) dry cough >(+)chest wall retraction >(+) use of accessory muscles >(+) shallow breathing >Diminished breath sounds.

8:00 am

clients position (High Fowlers) >Encouraged client to do deep breathing exercises and effective coughing. >Monitored bottle for fluctuation >Maintained O2 therapy @ 4lpm >Administered Salbutamol + Ipratropium through nebulization Monitored BP before and after meds. -meds given: Furosemide 20mg 1tab PO/ODx 3 days Enalapril 5mg 1tab PO/OD -Daily O2 Saturation and CBG taken BP within normal ranges. -O2 sat. 96% -CBG: 109 mg/ dL

8:30 am

Mas nakakahinga na ko ng maayos. RR- 20cpm

-Client has established an effective respiratory pattern -Client has shown improved ventilation

9:00 am

Masakit yung sa gilid ng dibdib ko, parang tinutusok tusok. (+) facial grimace (+) guarding at the affected area - Pain on the Left lateral chest P Exacerbates when coughing and moving. Q- Stabbing pain S- 6/10

--assessed pt. -v/s taken & recorded -medication given: Tramadol 50mg TIV

26

R Radiates to the left shoulder T 5-10 sec nanghihina ako, hinahapo pa ako tuwing bumabangon ako. >(+) fatigue
>Evaluated medications the client is taking to see if they could be causing activity intolerance. >Assessed nutritional needs associated with activity intolerance. >Monitored vitals before and after any activity, noting any abnormal changes. > Assessed for pain before activity. > Instructed client in energy-conserving techniques (e.g. carrying out activities at a slower pace).

9:30am

mga 3 nalang ang score kumpara kanina.

-client verbalized a decrease in the level of pain from 6/10 to 3/10

10:00am

-bed side care done -health teaching on chest tube drainage system provided -pt. verbalized understanding on chest tube system precaution - Temp: 36.9c RR: 23 cpm PR: 103 bpm -input & output measured -meds given: Ceftriaxone 2g TIV (loading dose) BP: 130/70 mmHg - Input Oral: 500 cc IV: 80cc Total: 580 cc

12:00 nn

- v/s taken and recorded

27

-encouraged ambulation

- urine output: 430 cc -Chest tube drainage output: 40cc Total: 470cc -BM: 0

2:00 pm

-Endorsed patient to the next shift

May 08, 2012 6am-2pm shift Time

6:00 am

Data
-received pt. sitting on bed, conscious and responsive

Action
-maintained pt. on sitting position

Response
-pt. verbalized increased comfort

-maintained o2 -continuous with O2 support via nasal cannula at 4LPM -monitored IV rate therapy

- With IV contraption on R metacarpal infusing PNSS 1L x KVO

-with CTT to thoraco bottle on L lower lateral chest wall at

-maintained patency

28

300water peak level.

of CTT

Initial H2O in CTT: 200

6:30am

mas okay tulog ko kumapara kahapon.

>Patient displayed improvements in sleeping pattern.

7:00 am

-v/s taken and recorded

-Temp : 36.9 c

RR: 23 cpm - medication given: methimazole 20mg 1tab PO afterbreakfast BP: 130/80 mmHg PR: 100bpm

8:00 am

-Monitored BP before BP: 110/70mmHg and after meds - meds given: Furosemide 20mg 1tab PO/ODx 3days Enalapril 5mg 1tab PO/OD -meds given: Ceftriaxone 500mg q 8 hours -Daily O2 Saturation and CBG taken From time to time may inaabot ako sa mesa. Makukulit mga kamag-anak ko dito sa pwesto ko. >Instructed to refrain
from lying or pulling on tubing. >Monitored changes and situations like change in sound of bubbling,

9:00 am

-O2 sat. 97% -CBG: 116 mg/ dL

29

>CTT bottle not secured under the bed. 10:00am Madalas wala dito ang asawa pag natutulog ako. >With left side rails down while client is in semi-fowlers position. >Caregiver is absent. >Limited ROM >(+) Body weakness May dugong nalabas sa tubo. Madalas akong naihi. 12:00 nn

sudden air hunger and chest pain, and disconnection of equipment.

>Ensured patients safety by raising the side rails >Advised client not to rise abruptly from a supine position >Provided emotional support to client
>Noted signs and symptoms of dehydration such as dry mucous membranes, and thirst. >Measured intake and output accurately.

10:30am

- v/s taken and recorded

- Temp: 36.9c RR: 23 cpm PR: 99 bpm BP: 120/80 mmHg

-input & output measured

- Input Oral: 300 cc IV: 320cc Total: 620 cc

-meds given: Ceftriaxone 500mg q 8 hours

- urine output: 480 cc CTT output: 30cc Total: 510cc -BM: 0

2:00 pm

-Endorsed patient to the next shift

-The client was free from injury and falls throughout the 8 hour nursing shift.

30

CHAPTER 9:

ANATOMY AND PHYSIOLO GY

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM Respiration is essential to all living things because all of the living cells in the body need adequate oxygenation and produces carbon dioxide. Respiratory System, in anatomy and physiology, comprises of organs that deliver o xy g e n t o t h e c i r c u l a to ry s ys t em fo r t r a n s po r t t o a l l b o dy ce l ls . O x y g e n i s e s se n t i a l fo r cells, which use this vital substance to liberate the energy needed for cellular activities. T h e r e s p i r a t o r y s y s t e m b r i n g s o xy g e n t h r o u g h t he a i r w ay s o f l u n g s i nt o t h e a l v e o l i , w h e re i t d i f f u s e s i n t o t h e b l o o d f o r t r a n s po r t to t he t i s s u e ; t h i s p r o ce s s is s o v it a l t h a t d i f f i c u l t i n breathing is expected as a threat to life in self. The respiratory system allows oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. The cardiovascular system transport oxygen from the lungs to the cells of the body and carbon dioxide. Without healthy respiratory and cardiovascular system, the capacity to carry out normal activity is reduced, a n d w i t h o u t a d e q u a te r e s p i r a to ry a n d c a rd i o v a sc u l a r s ys t em f ri c t i o n , life itself is possible.

A.NasalPassages The nose, the uppermost portion of the human respiratory system, is a hollow air passage that functions in breathing and in the sense of smell. W h i l e tr a n s p o r t i n g a i r to t h e p h a r yn x , t h e n a s a l p a s s a g e is vital because it p l a y s t w o c r i t i c a l r o l e s : t h e y f i l t e r t h e a i r t o r e m o v e po te n t i al l y d i s e a se - c a u s i n g p a rt i c l e s ; a n d t h ey m o is te n a n d w a rm t he a i r to p r o t e ct t h e s t r u c t u r e s i n t h e re s pi r a t o ry sy s t em .

31

B.Pharynx A i r l e a v e s t h e n a s a l p a s s a g e s a n d f l o w s to t h e p h a r y n x , a s h o r t , f u n n e l - s h a p e d tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the p h a r y n x i s lined with a protective mucous membrane and ciliated cells that

r e m o v e im p u r i t i e s fr o m t h e a i r . W h e n t he a d e n o i d s a r e s wo l l en , t h e y b l o ck t h e f l o w o f a i r f r o m t h e n a s a l p a s s a g e s t o t h e p h a r y n x , a n d a p e r s o n m u s t b r e a t h e through the mouth.

C.Larynx Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) l o n g located approximately in the middle of the neck. Several layers of cartilage, a tough and f l e x i b l e t i s s u e , c o m p r i s e m o s t o f t h e l a r y n x . While the primary role of the larynx is to transport air to the trachea, it also serves o t h e r f u n c t io n s . I t p l a y s a p r i m a r y r o le i n p r o d u c i n g s o u n d ; it prevents food and fluid from entering the air passage to cause choking; and its m u c o u s m em b r a n e s an d c i l i a - b e a r i n g c e l l s h e l p f i l t e r a i r .

D.Trachea,Bronchi,andBronchioles 32

Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the C are connected by muscle tissue. The base of the trachea is located a little below where the neck meets the trunk of t h e b o d y . H e r e t he t r a c he a b r a n c h e s i n t o two tubes, the left an d right bronchi, which d e l iv e r a i r branch to the le f t a n d ri g h t

l u n g s , r e s p e c t iv e ly .

Within

t h e l u n g s , t he

bronchi

into smaller tubes called

bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx. E.Alveoli The bronchioles divide many more times in the lungs to create an impressive tree w i t h s m a l le r a n d s m a l l e r b r a n c h e s , s o m e no l a r ge r t h a n 0 . 5 m m (0 . 0 2 i n ) i n d i am e t e r . T h e s e b r a n c h e s d e a d - e n d i n t o t i n y a ir s a c s ca l l e d a lv eo l i . T h e a l v eo l i d e l i v e r o xy g e n to t he c i r c u l at o ry s y s t em a n d r em o v e ca r b o n d i o x i d e . I n t e r sp e r s e d am o n g t h e a lv e o l i a re numerous macrophages, large white blood cells that patrol the alveoli and remove foreign s u b s t a n c e s t h a t h av e n o t b ee n f i l t e re d o u t e a r l i e r . T he m a c ro p h a g e s a r e t h e l as t l i n e of d e f e n s e o f t h e r e s p i r a t o r y s y s t e m ; t h e i r p r e s e n c e h e l p s e n s u r e t h a t t h e a l v e o l i a r e protected from infection so that they can carry out their vital role.

33

CHAPTER 10:

DIFFERENTIAL DIAGNOS IS

SIGNS AND SYMPTOMS Productive cough

PNEUMOTHORAX Absent

PLEURAL EFFUSION Present

PULMONARY EDEMA Present

Absent or diminished breath sounds on the affected side Tachypnea Dyspnea Difficulty of breathing Absent or diminished tactile fremitus on the affected side Dullness on the affected side when percussed Asymmetrical chest expansion Sharp chest pain exacerbated when coughing Orthopnea Lateral CXR: Opaque densities on the lower lobe, blunting of the costophrenic angle Posteroanterior CXR:

Evident

Evident

Not evident

Present Present Present Evident

Present Present Present Evident

Present Present Present Not evident

Absent

Present

Absent

Evident Present

Evident Present

Not evident Absent

Present Absent

Present Present

Present Absent

Air in the pneumo region shown is much darker than the air within the actual lung in the affected part

There is an area of whiteness in the affected area

Kerley lines: thin linear pulmonary opacities:

34

CHAPTER 11:
NON-MODIFIABLE: Age: 36 yrs. Old Sex: M Height: 172.72 cm Idiopathic causes Genetic Factors

PATHOPHYSIOLOGY
MODIFIABLE: High lung volume Weight: 54.4kg BMI: 18.2 Increased intrathoracic pressure (Underweight) Asthma Alveoli expands Smoking

Formation of air-filled blebs

Damage to lungs

Rupture of the blebs under superficial lung surface due to changes in pressure

Decrease in elastin and collagen

Communication between lung alveoli and pleural space

Thinning of alveolar walls

Lung deflates

Air escapes from the lungs

Decrease in elasticity of lung tissue

Parietal pleura is breached Air muffles flow of sound and vibration

Air enters the pleural space

Decreased breath sounds on affected lung

PNEUMOTHORAX
(Accumulation of air in the pleural space)

Decreased tactile fremitus Hyper resonant when percussed Pleural space exposed to positive pressure

35

Diminished vacuum or negative pressure

Equilibrium between elastic recoil forces of the lung & chest wall disrupted

Pleuritic chest pain

Irritation of sensory nerves in the parietal pleura during deep inspiration.

Decreased lung expansion on the affected site

Decreased volume of oxygen inspired on affected lung Assymetrical chest expansion

Atelectasis of affected area

Dyspnea Increase pressure on lungs when lying down Peripheral chemoreceptors respond to changes in PO2

Orthopnea

Decreased tissue oxygenation

Stimulation of SNS

Increase in heart rate Tachycardia Increased Cardiac contractility Increased rate of breathing Tachypnea

Increase in cardiac output

36

CHAPTER 12:

NURSING CARE PLANS

37

Assessment

Diagnosis

Inference

Planning

Nursing Intervention

Rationale Independent: 1. Regularly scheduled evaluation provides a baseline to evaluate resolution of pneumothorax .Respiratory distress and changes in v/s occur as a result of physiologic distress and pain, or may indicate development of shock due to hypoxia/ hemorrhage. 2. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion. 3. To establish a normal breathing pattern 4. To check for chest tube patency. 5. To determine if patient is bleeding from a vessel that was not cauterized during closure of chest or a ruptured graft. 6. To avoid kinking, damaging and any instances that will affect the drainage system. Dependent: 1. Oxygenation provides more o2 supply. 2. This medication dilates the bronchi and creates a better airway. Collaborative: 1. To monitor the progress of resolving pneumothorax and re-expansion of lungs.

Evaluation

S: Nahihirapan akong huminga O: > conscious and coherent > V/S: RR 27cpm >(+) facial grimace >(+) difficulty of breathing >(+) dry cough >(+)chest wall retraction >(+) use of accessory muscles >(+) Shallow respirations >Diminished breath sounds. >With under water seal Chest tube on the Left lung, 5th ICS, LMA line.

Ineffective breathing pattern related to decreased lung expansion.

Air accumulation in the pleural space

Increase pressure around the lungs

After 1 hour of nursing intervention, the Client will establish an effective respiratory pattern with a normal respiratory rate of 1620cpm.

Independent: 1. Auscultate breath sounds and evaluate respiratory function, noting rapid/shallow respirations, dyspnea,reports of air hunger, development of cyanosis, changes in v/s 2. Maintain the clients position (High Fowlers) 3. Encourage client to do deep breathing exercises and effective coughing 4. Monitor bottle for fluctuation 5. Monitor Chest tube drainage output.

Decreased lung expansion

After 1 hour of nursing intervention, the Client has established an effective respiratory pattern as evidenced by respiratory rate of 20cpm.

Inspiration/expiration doesnt provide adequate ventilation

6. Position chest tube drainage below the bed. Dependent: 1. Maintain O2 therapy @ 4lpm 2. Administer Salbutamol + Ipratropium . Collaborative: 1. Monitor Chest x-rays

Ineffective breathing pattern

38

Assessment

Diagnosis

Inference

Planning

Nursing Intervention

Rationale

Evaluation

S: Parang hinihingal ako. O: conscious and coherent > V/S: RR 27cpm PR 105bpm >(+) difficulty of breathing >(+) dry cough >(+)chest wall retraction >(+) use of accessory muscles >Diminished breath sounds. >With under water seal Chest tube on the Left lung, 5th ICS, LMA line.

Impaired Gas exchange related to decreased lung expansion secondary to air accumulation in the pleural space.

Air accumulation in the pleural space

Increase pressure around the lungs

After 1 hour of nursing intervention, the Client will have improved ventilation and adequate oxygenation

Independent: 1. Maintain patency of nasal cannula. 2. Monitor ABG results

Decreased lung expansion

3. Maintain clients High Fowlers position. 4. Have patient practice pursed lip breathing. 5. Encourage client to stop smoking Dependent: 1. Maintain O2 at 4 Lpm

Independent: 1. Clearing airways of secretions improves ventilationperfusion relationship. 2. ABG results provide integral information to determine deficits in capacity and effect of oxygen delivery. 3. To facilitate chest expansion 4. Promotes alveolar open 5. To decrease risk and prevent further decline in lung function Dependent: 1. To provide O2 to the clients body and balance ABG. Collaborative:
1. To monitor the progress

After 1 hour of nursing intervention, the Client has improved ventilation and adequate oxygenation and respiratory rate of 20 cpm

Decreased surface area for oxygen and carbon dioxide to exchange

Collaborative: 1. Monitor ABG and Chest X-ray results.

of the clients condition

Impaired Gas Exchange

39

Assessment

Diagnosis

Inference

Planning

Nursing Intervention

Rationale

Evaluation

S: Masakit ang dibdib ko, parang tinutusok tusok. O: > conscious and coherent > V/S: RR 27cpm >(+) facial grimace >Guarding at the affected area >Pain at the Left thoracic region. P Exacerbates when coughing and moving. Q- Stabbing pain S- 6/10 R Radiates to the left shoulder T 5-10 sec

Acute Pain related to impaired pleural integrity

Tissue damage

Peripheral neurotransmitters released Free nerve endings (nociceptors) triggered Signals travel to spinal cord

After 30 minutes of nursing intervention, the client will verbalize a decrease of level of pain from a score of 6/10 to a 3/10

Independent: 1. Monitor pain. Let the client describe the pain he feels.
2. Assist client on splinting

the painful area when coughing and deep breathing. 3. Provide a calm, quiet environment.

Independent: 1. Pain is subjective in nature, and only the patient can fully describe it. 2. Splinting the affected area may lessen the pain that the client feels. 3. Promotes action and effect of medication by providing decreased stimuli. 4. To detect changes that might indicate pain or a complication of pain. 5. Fatigue may contribute to an increased pain response, or pain can contribute to interrupted sleep. 6. To reduce pull or drag on latex connector tubing which could add up to the pain. 7. Enhances sense of control and may improve coping abilities. 8. Reduces muscle tension and anxiety associated with pain.

After 30 minutes of nursing intervention, the client has verbalized a decrease of level of pain from a score of 6/10 to a 3/10

4. Monitor vital signs.

Signals rerouted to appropriate area of brain Brain interprets quality and intensity of pain present

5. Monitor the sleeprest

pattern.

6. Maintain stability chest

tube.

7. Explain and

demonstrated the proper breathing exercise to the pt 8. explain and demonstrated cutaneous stimulation to

40

the pt 9. Explain the ways and benefits of diversional activities to alleviate the pain of the pt Dependent: 1. Administer Tramadol 50mg TIV

9. Enhances sense of wellbeing and helps forget the thought of pain. Dependent: 1. Analgesics given TIV reach the pain centers immediately, providing more effective relief with small doses of medication.

41

Assessment:

Nursing diagnosis:

Inference:

Planning:

Intervention:

Rationale:

Evaluation:

Subjective: Paputol-putol yung tulog ko dito kasi maingay at maya-maya ginigising ako. Objective: >Dark circles around the eyes > Weakness and restlessness. >Naps whenever possible. >Yawning

Disturbed Sleep Pattern related to interruptions for therapeutics, monitoring and other generated awakening and excessive stimulation (noise and lighting).

External noises and interruptions Excessive environmental stimulation Disruption of relaxation Reduced initiation of the body to induce sleep Patient is unable to obtain adequate sleep Disturbed sleep pattern

After 1 day of nursing intervention the patient will display improvements in sleeping pattern.

Independent: 1. Assess sleep pattern disturbances that are associated with the environment. 2. Observe and obtain feedbacks regarding on the usual sleeping pattern, bedtime routine and the usual number of hours of sleep and rest. 3. Do as much care as possible without waking up the client and do as much care as possible while the client is still awake. 4. Explain necessity of disturbances for monitoring Vital Signs and care when hospitalized. 5. Provide information about relaxation techniques (such as instrumental music and meditation). Dependent: 1. Administer sedatives as indicated

Independent: 1. High percentage of sleep disturbances can affect the recovery of the patient. 2. To determine usual sleeping pattern and to compare if there are any improvements on the sleeping pattern of the patient. 3. To avoid disturbances during sleep, and also to maximize the sleep and rest of the client.

After 1 day of nursing intervention the patient was able to display improvements in sleeping pattern.

4. For the patient to have an understanding of the importance of care being done to her and to minimize the complaints. 5. For the client to condition his body for sleeping.

Dependent: 1. Timely medication can enhance rest or sleep. 42

Assessment

Nursing diagnosis

Inference

Planning

Subjective: nanghihina ako, hinahapo pa ako tuwing bumabangon ako. Objective: >RR- 27cpm >Weak in appearance >(+) fatigue >thin in appearance >(+) DOB

Activity intolerance r/t generalized weakness and fatigue

Generalized weakness

Insufficient physical or psychological energy to endure or perform desired activities

After 2 hours of nursing intervention, the patient will be able to identify techniques in enhancing activity tolerance.

Intervention Independent: 1. Evaluate medications the client is taking to see if they could be causing activity intolerance.

2. Assess nutritional needs associated with activity intolerance.

Activity intolerance

3. Monitor vitals before and after any activity, noting any abnormal changes. 4. Assess for pain before activity.

Rationale Independent: 1. Medications such as beta-blockers, lipidlowering agents, which can damage muscle tissue, and some antihypertensive can result in decreased functioning. 2. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers. 3. This can be caused by a temporary insufficiency of blood supply 4. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement. 5. Energy-saving technique reduces the energy expenditure, thereby assisting in equalization of oxygen supply and demand. Collaborative: 1. Relief of pain can help increase tolerance to activities

Evaluation

After 2 hours of nursing intervention, the patient was able to identify techniques in enhancing activity tolerance

5. Instruct client in energyconserving techniques (e.g. carrying out activities at a slower pace).

Collaborative: 1. Administer analgesics as indicated

43

Assessment

Diagnosis

Inference

Planning

S: From time to time may inaabot ako sa mesa. Makukulit mga kamag-anak ko dito sa pwesto ko. O: > With under water seal Chest tube on the Left lung, 5th ICS, LMA line. >CTT bottle is not secured under the bed >Patient is restless

Risk for injury related to dependence on Chest tube Drainage system

Chest tube insertion

Chest tube Drainage system dependence

Client will be free from injury throughout the 8 hour nursing shift

Nursing Intervention Independent: 1. Instruct client to refrain from lying or pulling on tubing. Monitor changes and situations like change in sound of bubbling, sudden air hunger and chest pain, and disconnection of equipment. Provide safe transportation when client is sent off unit for diagnostic purposes. Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client.

Rationale Independent: 1. Reduces risk of obstructing drainage or inadvertently disconnecting the tubing. Timely intervention may prevent serious complications.

Evaluation

2.

2.

Client was free from injury throughout the 8 hour nursing shift

3.

CTT bottle is not secured under the bed

3.

4.

4.

Visitors constantly moving around the bed

5.

Risk for injury

6.

Monitor thoracic insertion 5. site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed. 6. Observe for signs of respiratory distress if thoracic catheter is disconnected/ dislodged.

Promotes continuation of optimal evacuation of fluid or air during transport. Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing. Provides for early recognition and treatment of developing skin or tissue erosion or infection.

Pneumothorax may recur/ worsen, compromising respiratory function and requiring emergency intervention

44

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Madalas wala dito ang asawa pag natutulog ako. Objective: >With left side rails down while client is in semifowlers position. >Caregiver is absent. >Limited ROM >(+) Body weakness

Risk for falls related to generalized weakness

Body weakness

Decreased muscle strength

Within the 8 hour nursing shift, the client will be free from falls

Independent: 1. Assess patients general condition 2. Ensure patients safety by raising the side rails 3. Monitor vital signs

Independent: 1. To determine the patients status 2. To keepthe patient from falling of f the bed whenmoving 3. To obtain baseline data 4. Abrupt change of position can lead to orthostatic hypotension 5. To decrease anxiety.

Within the 8 hour nursing shift, the client was free from falls

Lowered side rails

4. Advise client not to rise abruptly from a supine position

Patient is left unattended by the significant other

5. Provide emotional support to client 6. Create an individualized exercise program for the client

Risk for falls Collaborative: 1. Consult with dietician for proper diet and nutrition

6. Engaging in regular exercise and activity will strengthen muscles, improve balance, and increase bone density. Collaborative: 1. Proper nutrition and diet promotes body strength and bone density.

45

Assessment

Diagnosis

S: May dugong nalabas sa tubo. Madalas akong naihi. O: > With under water seal Chest tube on the Left lung, 5th ICS, LMA line. > With ongoing IVF, PNSS 1L x 40cc/ min attached to patients right metacarpal vein. > Client is also under medication of Furosemide 20mg, 1 tab OD x 3 days

Risk for deficient fluid volume related to treatment regimen

Inference Treatment regimen (chest tube drainage system and Furosemide medication)

Planning

Collection of blood and air from the chest tube. Furosemide creates diuresis

Throughout the 8 hour nursing intervention, the client will be able to maintain a near balance between intake and output.

Nursing Intervention Independent: 1. Measure I&O accurately. Weight daily. Calculate insensible fluid losses. 2. Encourage enough fluid intake as necessary. Provide allowed fluids throughout 24 hour period. 3. Monitor BP, noting postural changes and heart rate

Rationale Independent: 1. Helps estimate fluid replacement needs. 2. To replace needed fluids by the body.

Evaluation

3. orthostatic hypotension and tachycardia suggest hypovolemia 4. For immediate prevention of severe dehydration.

Throughout the 8 hour nursing intervention, the client was able to maintain a near balance between intake and output

Decreased fluid in the body

4. Note signs and symptoms of dehydration such as dry mucous membranes, thirst, dulled sensorium and peripheral vasoconstriction 5. Control environmental temperature, limit bed linens as indicated. Collaborative: 1. monitor labs studies such as sodium

5. may reduce diaphoresis which contributes to overall fluid losses. Collaborative: 1. To gain a more accurate assessment of the patients condition

Risk for deficient fluid volume

46

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Di ako masyado nakakagalawgalaw. Objective: >Client is conscious and coherent >Limited ROM >(+) Body malaise

Risk for Body weakness constipation related and lack of to changes in level privacy of activity

Decrease in level of activity

Decreased stimulation of the smooth muscles of the G.I tract.

After 1 hour of nursing intervention, the Client will verbalize understanding of ways in improving bowel elimination patterns an effective respiratory pattern.

Decrease in peristalsis

Independent: 1. Ascertain usual bowel pattern and aids used. Compare with current routine. 2. Provide diet high in fiber bulk in the form of wholegrain cereals, breads, and fresh fruits. 3. Encourage increased fluid intake. 4. Institute an individualized program of exercise, rest, and diet. 5. Provide emotional support to client Dependent: 1. Administer medications as indicated (e.g. bulk providers and stool softeners)

Independent: 1. Determines extent of problem and indicates types of interventions appropriate. 2. Improves stool consistency, promotes evacuation

3. Promotes normal stool consistency. 4. Increase in activities and movement increases peristalsis.

After 1 hour of nursing intervention, the Client has verbalized understanding of ways in improving bowel elimination patterns an effective respiratory pattern

Risk for constipation

5. Decreases feelings of embarrassment and frustration. Dependent: 1. Promotes regularity by increasing bulk or improving consistency.

47

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Mahirap tumigil sa pagyoyosi eh. OBJECTIVE: >Request for Information about the disease process. >Inaccurate follow through of instructions. > Demonstrates nonacceptance of health status change.

Risk for Prone health behavior related to lack of knowledge about the disease

Lack of knowledge about the disease process

Reduced motivation to modify lifestyle

After 4 hours of nursing interventions, the patient will demonstrate increase in interest and participation in self-care

INDEPENDENT: 1. Establish rapport 2. Assess patients general condition. 3. Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol, smoking, and drinking. 4. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. 5. Identify with the client past and present significant support systems (family, church, groups and organizations). 6. Identify possible cultural beliefs / values influencing clients response to change. 7. Acknowledge clients efforts to

INDEPENDENT: 1. To prevent patient anxiety and establish cooperation 2. To determine patients status. 3. These risk factors have been shown to contribute to the development of several types of diseases.

After 4 hours of nursing interventions, the patient will demonstrate increase in interest and participation in self-care

Reduced interest in selfcare

Risk for prone health behavior

4. Provides basis for understanding of the condition. Lack of cooperation may lead to failure of therapy. 5. Identifies helpful resources that may be needed in current situation.

6. Different cultures deal with change of health issues.

7. Avoids feelings of 48

adjust: You have done your best. Collaborative: 1. Refer to spiritual adviser in necessary

blame / guilt and defensive response. Collaborative: 1. For the client to be given spiritual counseling.

49

CHAPTER 13 :

DRUG STUDY

50

DRUG NAME

CLASSIFICATION

BRAND NAME: Reglan

Antiemetic, Dopaminergic blocker, GI stimulant

GENERIC: Metoclopramide

MECHANISM OF ACTION Stimulates motility of upper GI tract without stimulating gastric, biliary or pancreatic secretions. Sensitizes tissues to action of acetylcholine Relaxes pyloric sphincter, which when combined with effects of motility Accelerates gastric emptying and intestinal transit; little effect on gallbladder or colon motility Increases esophageal sphincter pressure, has sedative properties Induces release of prolactin.

INDICATION

DOSAGE/ROUTE/FREQUENCY

NURSING CONSIDERATIONS

EVALUATION

-Relief of symptoms of acute and recurrent gastroparesis. -Stimulation of gastric emptying and intestinal transit of barium.

10 mg/ TIV/ now then PRN for nausea & vomiting.

-Assess for allergy to metoclopramide, GI hemorrhage, mechanical obstruction or perforation, epilepsy. -Assess the patients orientation, reflexes, VS, bowel sounds, normal output, EEG. -Monitor BP carefully during IV administration. -Monitor for extrapyramidal reactions, and notify physician if they occur. -Report involuntary movement of the face, eyes, limbs, severe depression & severe diarrhea.

-The patients VS were monitored, in normal ranges during IV administration. -Nausea and vomiting was prevented.

51

DRUG NAME BRAND NAME: Propyl-Thyracil

CLASSIFICATION Antithyroid drug

MECHANISM OF ACTION Inhibits the synthesis of thyroid hormones

INDICATION

DOSAGE/ROUTE/FREQUENCY

Hyperthyroidism 50 mg / 1 tab per orem/ q6

GENERIC: Propylthiouracil Partially inhibits the peripheral conversion of T4 to T3 the more potent form of thyroid hormone.

NURSING CONSIDERATIONS -Asses for allergy to antithyroid drugs. -Assess the patients skin color, lesions, pigmentations, orientation, reflexes. -Administer drug in three equally divided doses at 8 hour intervals, schedule to maintain patients sleep pattern. -Arrange for regular, periodic blood tests to monitor bone marrow depression and bleeding tendencies. -Report fever, sore throat, unusual bleeding or bruising. Headache & general malaise.

EVALUATION -The clients thyroid hormones are within normal levels.

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DRUG NAME BRAND NAME: Vasotec GENERIC: Enalapril

CLASSIFICATION ACE inhibitor, Antihypertensive

MECHANISM OF ACTION Renin released into circulation Acts on a plasma precursor to produce angiotensin I Converted by ACE to angiotensin II Increases BP. Blocks the conversion of angiotensin I to angiotensin II Decreases BP and aldosterone secretion, slightly increases serum K+ levels and causing Na+ and fluid loss.

INDICATION Treatment of hypertension

DOSAGE/ROUTE/FREQUENCY 5 mg/ 1 tab Per Orem/ OD

NURSING CONSIDERATIONS -Assess for allergy

to enalapril, impaired renal function, salt or volume depletion. -Assess patients skin color, lesions, turgor, orientation, reflexes, peripheral sensations, VS, mucous membranes, bowel sounds and liver evaluation. -Monitor patient on diuretic therapy for excessive hypotension after the first few doses of enalapril. -Monitor patient closely in any situation that may lead to a drop in BP secondary to reduced fluid volume (excessive perspiration, and dehydration, vomiting and diarrhea).

EVALUATION -Patient was monitored closely for any situation that might lead to a drop in BP. -Patients blood pressure is within normal ranges.

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DRUG NAME BRAND NAME: Apo-Furosemide

CLASSIFICATION Loop diuretic

GENERIC: Furosemide

MECHANISM OF ACTION Action at the proximal and distal tubules and ascending limb of the loop of Henle

INDICATION For mild to moderate hypertension

DOSAGE/ROUTE/FREQUENCY 20 mg/ 1 tab Per Orem/ OD x 3 days

NURSING CONSIDERATIONS
-Assess allergy to medication. -Assess the patients skin color, lesions. -Reduce dosage if given with antihypertensive drugs , readjust dosage gradually as BP responds. -Give early in the day so that increased urination will not disturb sleep. -Avoid IV use if oral use is at all possible. -Measure and record weight to monitor fluid changes. -Arrange to monitor serum electrolytes, hydration, liver and renal function. -Arrange for potassium rich diet or supplemental potassium as needed.

EVALUATION -Patients sleep pattern was not disturbed. -Patients blood pressure is within normal ranges.

Inhibition of reabsorption of sodium and chloride

Leads to a sodium-rich diuresis.

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DRUG NAME BRAND NAME: InnoPran XL

CLASSIFICATION Antianginal, antiarrhythmic. Antihypertensive, Beta-adrenergic blocker (non selective)

GENERIC: Propranolol

MECHANISM OF ACTION Completely blocks betaadrenergic receptors in the heart and juxtoglomerular apparatus Decreases the influence of sympathetic nervous system on these tissues, the excitability of the heart, cardiac workload and O2 consumption, and the release of renin and lowering BP.

INDICATION For adult hypertension

DOSAGE/ROUTE/FRE QUENCY 20 mg/ 1 tab Per Orem/ q8

NURSING CONSIDERATIONS -Assess allergy to betablocking agents, sinus bradycardia, second or third degree heart block, cardiogenic shock, peripheral vascular diseases. -Assess the patients weight, skin color, lesions, edema, reflexes. -Provide continuous cardiac and regular BP monitoring with IV form. -Give oral drug with food to facilitate absorption. -Report difficulty of breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash fever, sore throat.

EVALUATION Patients cardiac status and BP were maintained within the normal range.

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DRUG NAME BRAND NAME: Tapazole

CLASSIFICATION Antithyroid drug

MECHANISM OF ACTION Inhibits the synthesis of thyroid hormone.

INDICATION Treatment of hyperthyroidism.

DOSAGE/ROUTE/FREQUENCY Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinner

NURSING CONSIDERATIONS
-Assess allergy to antithyroid products. -Assess for skin color, lesions, pigmentation, orientation. Reflexes. -Give drug in three equally divided doses at 8-hr interval. -Establish a schedule that fits the patients routine. -Advise the patient that taking this drug could increase the risk of bleeding problems. -Report fever, sore throat, unusual bleeding or bruising, headache and general malaise. -Obtain regular, periodic blood tests to monitor bone marrow depression and bleeding tendencies.

EVALUATION -Thyroid storm was prevented. -Patient did not develop any allergies to the medication

GENERIC: Methimazole

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DRUG NAME BRAND NAME: Rocephin

CLASSIFICATION Antibiotic, Cephalosporin (third generation)

MECHANISM OF ACTION Binds to receptors of bacterial cells

INDICATION Lower respirations infections

DOSAGE/ROUTE/FREQUENCY 2g/ TIV/ OD (loading dose) 500mg for consecutive doses TIV q8

GENERIC: Ceftriaxone Inhibits synthesis of bacterial cell wall

Causes cell death

NURSING CONSIDERATIONS -Assess for hepatic and renal impairment. -Assess the skin status, renal function tests, culture of affected area, sensitivity tests. -Advice the patient that he may experience stomach upset and diarrhea. -Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at the injection site. -Discontinue if hypersensitivity occurs.

EVALUATION Patient was monitored closely for stomach upset and diarrhea.

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DRUG NAME BRAND NAME: Titradose

CLASSIFICATION Vasodilator

MECHANISM OF ACTION Relaxes vascular smooth muscle with a resultant decrease in venous return Decrease in arterial BP Reduces left ventricular workload Decreases myocardial oxygen consumption

INDICATION Treatment and prevention of angina pectoris/ chest pain

DOSAGE/ROUTE/FR EQUENCY 5mg/tab/ 1 tab OD for chest pain

GENERIC: Isosorbide Dinitrate

NURSING CONSIDERATIONS -Assess for any allergy to nitrates, severe anemia, GI hypermobility. -Assess for skin color, lesions, orientation, reflexes. -Monitor effectiveness of drug in relieving angina. -Headaches tend to decrease in intensity and frequency with continued therapy but may require administration of analgesic and reduction in dosage. -Make position changes slowly, particularly from recumbent to upright posture, and dangle feet and ankles before walking. -Keep a record of angina attacks and the number of sublingual tablets required to provide relief.

EVALUATION Patient was monitored closely and chest pain was relieved.

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DRUG NAME BRAND NAME: DuoNeb

CLASSIFICATION Antiasthmatic & COPD preparations

MECHANISM OF ACTION
IPATROPIUM: Anticholinergic agent inhibits vagally-mediated reflexes by antagonizing the action of acetylcholine. Prevents the increase in intracellular concentration of cyclic guanosine monophosphate w/c are brought about by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle. SALBUTAMOL: Direct acting Beta2-adrenergic agent. Acts on the airway smooth muscle resulting in bronchodilation.

INDICATION Provides inhalation for DOB.

DOSAGE/ROUTE/FR EQUENCY 1 nebule Q6 PRN for DOB

GENERIC: Salbutamol + Ipatropium

NURSING CONSIDERATIONS -Monitor respiratory status; Auscultate lungs before and after inhalation. -Report treatment failure (exacerbation of respiratory symptoms) to physician. -Do not allow the solution to enter the eyes. -Allow 30-60 seconds between puffs for optimum results. -Advice patient to wait for 5 mins between this and other inhaled medications. -Let the patient rinse mouth after medication puffs to reduce bitter taste.

EVALUATION Patients DOB was managed and relieved.

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DRUG NAME

CLASSIFICATION

ACTION

INDICATION

DOSAGE/ROUTE/FREQ UENCY

NURSING CONSIDERATIONS

EVALUATION

BRAND NAME: Tramadine

Analgesics (opioid)

GENERIC NAME: Tramadol

Inhibits reuptake of norepinephrine, serotonin and enhances serotonin release.

Indicated for the management of moderate to moderately severe pain.

50mg TIV p.r.n. q6

-Assess type, location, -Client has verbalized and intensity of pain that pain was either before and 2-3 hr reduced or relieved. (peak) after administration. -Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression -Discontinue drug and notify physician if S&S of hypersensitivity occur. -Assess bowel and bladder function; report urinary frequency or retention. -Monitor ambulation and take appropriate safety precautions.

Inhibits reuptake of norepinephrine, serotonin and enhances serotonin release.

Decreased pain

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CHAPTER 14:

DISCHARGE PLAN

Medications: Inform the client the importance of compliance with taking the medications as prescribed by the physician. Continue medications prescribed such as: Methimazole 20mg 1 tab Per Orem after breakfast Methimazole 5mg/ tab 2 Per Orem tab after dinner Pain medication should be given on discharge. Exercise: Instruct on Deep Breathing Exercise and effective coughing Instruct patient to avoid extremes exercises, which will lead him to stress; and as to avoid shortness of breath. Instruct client to perform exercise as tolerated Treatment: Instructed client to continue steam inhalation and gentle chest physiotherapy.

Health Education: Self care: Encourage patient to avoid doing strenuous activities Chest tube wound site should be monitored for infection and to ensure proper healing. Encourage patient to stop smoking and avoid excessive alcohol intake Encourage other members of the family to stop smoking. Provide information about Pneumothorax and its signs and symptoms to avoid another occurrence in the future. Advise client to maintain only one sexual partner to avoid STI Home Care: 61

 Encourage to have a regular BP check-up at the nearest barangay health station Keep an environment free of air and noise pollution. OPD follow up: Instruct patient to return if there is chest pain or shortness of breath Teach patient when to notify the physician of complication (e.g. infections and an unhealed wound) Review all follow- up appointments with the patient, involving chest x-rays, arterial blood gas analysis, and a physical exam.

Diet: Instructed client on regular fluid intake and regular diet Eat food high in protein and high in calories. Foods such as milk, nuts and peanut butter, and fatty cuts of meat can help to add needed nutrients. Eat food with enough calcium contents such as dairy products. Avoid excessive intake of caffeine such as tea, cola, and coffee Decrease incorporation of table sugar in drinks and food

Spirituality: Support clients religious practices. Refer client for spiritual counseling.

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CHAPTER 15:

REFERENCES

1. Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010) Textbook of Medical-Surgical Nursing 12th edition. Lippincott Williams &Wilkins. Philadelphia, USA. 2. A.D.A.M. Inc (August 10, 2007). Medline pneumothorax. www.adam.com

3. Fischback, F.T. (2004) A manual of laboratory and diagnostic tests 7th ediction. Lipincott Williams &Wilkins. USA 4. Lippincott, Williams, and Wilkins. (2003) Nursing 2003: Drug Handbook 23rd edition. Lippincott Williams &Wilkins. USA 5. Medscape. (August 28, 2006). Emedicine pneumothorax. www.emedicine.com 6. Kozier, B., Erb, G., Snyder, S.J., Berman, A. (2007). Kozier &Erbs Fundamentals of Nursing 8th edition. Pearson Education, Inc. Philippines. 7. Doenges, M.E., Moorhouse, M.F., Geissler Murr, A.C. (2004). Nurses pocket guideL Diagnoses, interventions and rationales 9th edition. F.A. Davis Company. Thailand. 8. Netporfolio.Inc. (n.d.) What is a spontaneous pneumothorax?www.pneumothorax.org 9. Netporfolio.Inc. (n.d.) What is a tension pneumothorax?www.pneumothorax.org

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